What are some examples of pathological influences on mobility?
- Postural abnormalities - e.g. scoliosis, lordosis, kyphosis, club foot, knock knee
- Damage to CNS - spinal cord injuries, MS = multiple sclerosis
- Musculoskeletal Trauma
- Impaired muscle dvlpmt - muscular dystrophy
- decreased...
what are some examples of pathological influences on mobility
what is chvosteks sign
what are some therapeutic reasons for bed rest
what is cbr
what is brp
what is bsc
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Exam #2 - NUR 1022C - Foundations of
Nursing
What are some examples of pathological influences on mobility? - ANSWER- Postural
abnormalities - e.g. scoliosis, lordosis, kyphosis, club foot, knock knee
- Damage to CNS - spinal cord injuries, MS = multiple sclerosis
- Musculoskeletal Trauma
- Impaired muscle dvlpmt - muscular dystrophy
- decreased flexibility
What is chvostek's sign? - ANSWERPush the cheek and it spasms
(low calcium) due to hypocalcemia
What are some therapeutic reasons for bed rest? - ANSWERDefinition: Mobility
restriction where the pt. Is confined to their bed for Tx reasons i.e. Weakness,
decreased O2 consumption, major surgery/ blood loss, to rest a body part I.e. fractures,
safety reasons, reduces pain, preeclampsia
What is CBR? - ANSWERComplete Bed Rest, pt uses a bedpan
What is BRP? - ANSWERBed rest with bathroom privileges, pt should use the call light
What is BSC? - ANSWERBed rest with bedside commode, usually with assistance
What is dangle on the side of bed? - ANSWERUsed with hypotensive pts, pts who have
had major surgery
What is up to bedside chair? - ANSWERThe pt goes from bed to bed side chair, always
use another nurse for heavy pts.
What is disuse atrophy? - ANSWERWhen cells and tissues reduce in size due to disuse
What is OOB with assistance? - ANSWEROut of bed with assistance
What is OOB Ad lib? - ANSWEROut of bed at liberty, they can freely walk around, make
sure catheters/foleys are empty, supportive shoes
What are the systemic effects of immobility? - ANSWER- Glucose intolerance > high
blood glucose
- decreased calcium absorption > bone breakdown (osteoporosis)
- decreased peristalsis > fecal impaction/ constipation
- muscle breakdown > negative nitrogen balance > fatigue
- atelectasis (collapsed alveoli)
- pts can 't expand their lungs as often > can't move secretions out of their respiratory
track > secretions can end up in their lungs > hyperstatic pneumonia
- decreased metabolic activity, metabolize protein in the muscles
, Exam #2 - NUR 1022C - Foundations of
Nursing
- orthostatic hypotension, decreased cardiac output, blood clots due to reduced
circulation, ischemia > necrosis, tachycardia
- urine can stay in the pelvic area and lead to renal calculus aka kidney stones
- urinary retention > infection
- pressure ulcers
- psychosocial issues - depression, anxiety
What is hypostatic pneumonia? - ANSWERAn infection of the lungs associated with
immobility caused by pts not being able to take deep breaths or cough
What are the metabolic changes that can occur due to immobility? - ANSWERMuscle
atrophy (cells and tissue decrease in size due to immobility), protein muscles
breakdown into amino acids, amino acids breakdown into nitrogen. The pt basically
loses more nitrogen then they can intake > protein supplements
Can lead to anorexia (not hungry, no appetite) and fatigue
What subjective data can a nurse collect as part of her respiratory assessment on a pt?
- ANSWERCan the pt cough?
Does the pt have SOB?
Does the pt have angina w/ breathing? (maybe pleuritic)
Does the pt have a hx of respiratory disease? (Asthma, COPD)
Does the pt smoke?
What objective data can a nurse collect as part of her respiratory assessment? -
ANSWERChest shape (e.g. barrel shape = continuous over inflation of the lungs,
kyphosis)
Positioning (tripod, laying down using pillows due to orthopnea)
Color ( cyanotic, pallor)
Symmetric expansion (do they have fractured ribs or pneumothorax?)
WOB (are they using accessory muscles?)
Sputum color ( e.g. pink = heart failure, clear = cold, bronchitis, yellow/green = bacterial
infection)
What measurements can a nurse use to assess a pt's respiratory function? -
ANSWERPulse oximetry (are their O2 stats greater than 95%?)
Cap refill (can tell the nurse if the pt has good peripheral perfusion)
Temperature (are they the same temp on both sides of their body? Are their fingers and
toes cold? If so, this can indicate poor peripheral perfusion)
Lung sounds (Are they diminished? Are they clear? Does the pt have crackles or
wheezing? Do they have patent airways?)
What does TCDB mean? - ANSWERturn, cough, deep breathe every 2 hours,
respiratory intervention
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